Laserfiche WebLink
SWRCB,January 2002 <br /> Page 1 of I <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> Pages of this form to report results for all components tested. The completedfarm, written testproeedures, andprintouts from tests <br /> (if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> =,m <br /> CHEVRON#98264 Date of Testing: 2/3/2012 <br /> ss:3775 N.TRACY BLVD ,TRACY,CA 95376 <br /> ct:MGR-PAT Phone:836-9422 <br /> ency Was Notified of Testing: <br /> l Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> pTechnicianCondu7cfing <br /> NKNOLOGY INC. <br /> cting Test: Pablito Piloton <br /> SLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Number: 8009643 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> PHIL-TITE PHASE I 8/2/2012 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail NotRepair Component Pass Fail Not Repairs <br /> Teste Made Tested Made <br /> Spill Box Tl SUPREME F X <br /> Spill Box T2 PLUS F X <br /> Spill Box T3 REGULAR F X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: TEST WATER FILLED IN ON <br /> THE LIQ.WASTE DRUMS ON SITE. <br /> CERTIFICATION OF TECBNICIAN RESPONSH3LE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 75?M Date: 2/3/2012 <br />